Westerleigh

Updated 14 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Act.

Inspection team

An inspector carried out the inspection.

Service and service type

Westerleigh is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection a manager was not yet registered with the Care Quality Commission. The last registered manager left in February 2023 and a new manager had been recently appointed but had subsequently left the service.

Notice of inspection

The inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local commissioners and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 12 people who used the service and 2 relatives. We spoke with two regional managers, the quality director, the quality manager, the manager, the deputy manager and 10 staff members. We also contacted all the staff via email.

We reviewed a range of records, which included 8 people’s care records, medicine records, staff files and a variety of records relating to the management of the service, including policies and procedures.

Updated 14 June 2023

About the service

Westerleigh is a residential care home providing personal care for up to 55 people who are mainly aged 65 and over. At the time of the inspection the service were supporting 50 people. The service is arranged over three floors and supports people with a range of conditions including those living with dementia.

People’s experience of using this service and what we found

Since 2021 the service has had difficulties around ensuring medicine management was effective and safe. The senior management team were now proactively addressing the issues.

People felt safe. In conversation staff understood people's needs and how to manage any presenting risks. Many of the risk assessments on the electronic care records had not been completed. Those in place, needed to be accurate and more detailed, which the management team alongside staff were working to do.

Albeit the provider had a dependency tool in place, which determined how staff numbers were needed, factored in the layout of the building and minimum staffing levels this had not been used consistently. This had led to variations in staffing levels across shifts. The management team undertook to resolve this matter.

Due to the challenges of the pandemic and staffing crisis in social care there had been a high turnover of staff and increase in sickness levels, which was mitigated via the use of agency staff. The provider was actively seeking to fill vacancies and reduce their reliance on agency staff.

Staff had training on how to recognise and report abuse and they knew how to apply it. However, at times it was unclear from the records whether all incidents had been reported to appropriate authorities or if staff always recognised the need to record and report incidents. The management team were in the process of reviewing records and have discussions with staff to check whether alerts had been raised when needed.

The management team understood how closely monitored accidents and incidents to understand trends, then determine what action could be taken to reduce potential risks. This at present was impaired by the fact staff were not completing the electronic incident analysis and lesson learnt tools.

Staff did not feel confident when applying the Mental Capacity Act 2005 and associated code of practice to their practice. The management team were providing additional training.

Systems were in place to ensure checks were carried out on the environment and staff knew how to keep people safe. The management team were in the process of ensuring all staff completed simulated evacuations and undertook regular fire drills.

People and their relatives spoke positively about the care they received from the service and the staff. They told us the staff were extremely supportive and very caring. We observed staff to be very empathetic, caring and worked tirelessly to meet people’s needs.

We found recruitment practices were meeting requirements.

The provider had been very responsive when the recent concerns had been identified by the latest manager. They recognised the need to work with staff to develop their practices. The provider had deployed a full range of resources and were giving the team time to make the necessary changes. They were completing regular audits, which were robust and a honest reflection of the service. They had completed a development plan and were working diligently to ensure the goals were achievable and completed in a timely manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 27 February 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

This report only covers our findings in relation to the key questions safe and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westerleigh on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.